Dental Sleep Medicine Insider April 2016 | Page 12

LESIA CRAWFORD DED, EOB, WTF?!? DED Abbreviation for “Deductible” This is how much money the patient is supposed to spend out of their pocket until the benefit of insurance actually starts. Some plans have doctor visits and preventive care available that is not subject to the deductible. We are not in that group; for us, deductibles usually apply only to OAT. FAM DED “Family Deductible” This means that each family member has their own deductible to meet, but there may be a limit or cap and once it is met by any family member it starts benefits for the whole family. For instance, the plan has a $1500 individual deductible per covered family member and a $3000 family deducible. Mom has a baby, met her $1500 deductible, Johnny crashed his bike and had 5 teeth knocked out and implants, bone grafting and implant crowns are placed and he met his $1500 deductible. Dad goes in for a sleep study and gets an oral appliance to treat his sleep apnea, he does not need to meet his deductible because the family deductible has been satisfied. Get it? Got it? Good! OOP MAX “Out of Pocket Maximum” This is a fun one. That’s sarcasm. Once the patient has paid their deductible and had medical services done and paid a % of the bills, the insurance company is willing to pony up at 100% coverage once this maximum amount of money paid out of pocket has been met. Depending on the plan this might be $1500. It might be $5k, $10k; it just depends. It serves as a safeguard so a patient will not go bankrupt for medical treatment….until next year that is when they all re-set. EXCLUSION FOR DME Unfortunately, we have run across some medical plans that have an exclusion for some or all DME supplies. When we call for a benefit verification or use an online tool we are specifically looking for the DME benefits, as they could be different then traditional benefits and services. If the Medical plan has an exclusion for DME supplies, do not assume the representative is aware of what specific DME supply you are referring to. The plan may not pay for crutches and boots but If CPAP is covered, then OAT should be as well. CEO of GoGo Billing GoGo Billing offers help with Tricare registration for no charge and Medicare credentialing services for DME, Part B and Ordering and Referring. Enter code DS3100 for $100.00 off DME and Part B credentialing. Contact me at [email protected] or call [phone] ext. 1. MEDICAL NECESSITY This is an unknown term in dentistry but to your medical biller, this is the golden key for approvals and insurance payments. Translated to dental, proving “medical necessity” would equate to “proving need for dental treatment.” Let’s say tooth #3 needs an MOB composite filling. Decay can be proven with an x-ray and visual exam. The dentist diagnoses and documents the problem, then plans the treatment. It’s the same idea with sleep medicine but the burden of proof is called “medical necessity.” The patient was screened, tested, diagnosed and then a plan for treatment was given. LOMN/ RX Expounding on the previous definition, the letter of medical necessity and prescription for treatment (LOMN/ RX) is the actual key. This letter, or form, spells out the patient’s diagnosis and co-morbidities and then explains the need for treatment and outcome if the condition is not treated. It should also list the name of the physician ordering the treatment and the providing dentist. Length of need for treatment should be listed as lifetime. DS3 has the perfect template form built right into the software as well as a cover letter that can be easily sent to the primary care doctor or sleep physician. EOB This one is the same in Medical as it is in Dental, “Explanation of Benefits.” The EOB should list the patient’s and subscriber’s names, the treating doctor (that would be you), the date of service and itemized procedures and fee’s. It should also list the “allowed amounts” or negotiated fee, the patient deducible, patient co-pay and amount paid to the patient or the provider. Congrats! You are now fluent in medical billing-ese or at least you can understand what your medical billing company is talking about. If you would like a sample letter of medical necessity please email me and reference this article. [email protected] 12